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Background: Ghana introduced what has come to be known as the ‘Free’ Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare. Purpose: This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana. Methods: This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with ‘svy’. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the ‘free’ policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis. Discussion: The study discussions will show the contributions of the ‘free’ policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred. Protocol approval: This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.
Studies on perinatal health care outcomes in Ghana are scanty and restricted. Existing studies often bothered on stillbirths reported within districts and institutions [20, 21, 45]. Despite the contributions of earlier studies to literature, their findings are limited in scope and do not allow for conclusion relative to in-country strides towards the achievement of the sustainable development goal 3. The limited research on policy impact on neonatal death highlights the challenges of inadequate research in Ghana context. Of critical importance to policy, continuity is the need to assess policy gains overtime after policy implementation [48, 46]. The one hunch of the ‘free’ policy in its prospect, was to bridge the financial gap to maternal healthcare access and create a situation of increased utilization in maternal healthcare. Nevertheless, copious literature exists to suggest that service providers are rather owed huge sums of monies, a situation which leads to service provider ineffectiveness due to acute shortages of supplies and consumables [43, 47, 51]. This current study aims to measure the impact of the ‘free’ maternal healthcare policy; firstly, on maternal healthcare utilization and secondly, on the effect of facility utilization on stillbirth, perinatal death, and neonatal mortality. Specifically, the study adopts quasi-experimental methods of propensity score matching technique and difference-in-differences analysis to determine the ‘free’ policy contributions towards the uptake of antenatal care and facility delivery utilization, and its impact in reducing stillbirth, perinatal deaths, and neonatal mortality. As a novelty, this study also collects qualitative data in an intrinsic case study style, using in-depth interviews and focus group discussions (FGD) to explain the context within which the so-called ‘free’ policy operates. Impact evaluation design is broadly categorized into two; prospective evaluation design and retrospective evaluation design. The former is designed during the program design stage and incorporated into the implementation plan, in which case, baseline data is collected at the pre-implementation stage using pre-defined variables of interest. Treatment assignment in prospective designs has the advantage of randomization, which is the gold standard. However, not all programs have the benefits of randomization, particularly, public health programs which are usually targeting populations such as poor communities and vulnerable groups. In these situations, it becomes crucial to adopt quasi-experimental design techniques in evaluating the program in the absence of randomization [49–58]. This is referred to as retrospective design, and is the method of choice for this study, giving the social policy status of the ‘free’ maternal health care policy. Retrospective design is usually the option available when impact evaluation was not envisaged and incorporated in a public program at the design stage, and in this case, statistical techniques are used to generate the propensity score of treated and untreated units’ characteristics for comparison to determine the treatment difference [49, 51, 52].
